Individual Exchange Participation Fees. (a) Contractor understands and agrees that (i) under the Affordable Care Act and the California Affordable Care Act, the Exchange may generate funds through a participation fee (“Participation Fees”) on Contractor’s QDPs and (ii) Contractor is responsible for the timely payment of any Participation Fees to the Exchange. (b) Contractor recognizes that the total cost of all Participation Fees for the Exchange must be collected by Contractor by spreading the cost across the premiums charged to Contractor’s entire individual risk pool (both inside and outside the Exchange) for the Individual Exchange Participation Fees and across the small employer risk pool (both inside and outside the Exchange) for Covered California for Small Business Participation Fees. No rate charged to an Enrollee can have a higher per member per month fee to cover this overall Participation Fee than is charged to all other Enrollees of the respective risk pool. (c) The Participation Fee payable to the Exchange during each month of this Agreement shall be equal to a per member per month (“PMPM”) rate of $.83 multiplied by the number of Enrollees in Contractor’s QDPs for such month. The Participation Fee will be assessed by the Exchange and payable monthly by Contractor based on enrollment in Contractor's QDPs sold through the Individual Exchange for 2016. (d) Participation Fee invoices will be issued by the Exchange prospectively to Contractor on the 15th of the month for the coming month. Contractor’s Participation Fee obligation will be determined and billed by evaluating Contractor’s then-current QDP confirmed enrollment and may be subject to adjustment to reflect changes in enrollment that may have occurred in prior months (including additions, terminations and cancellations of enrollment). However, Contractor may reconcile the invoice and remit payment only for those members who are enrolled in a QDP with Contractor in accordance with Billing Discrepancy Report in Attachment 13. Participation Fee payments will be due on the 1st of the month the Participation Fee covers. For Participation Fees received after the 15th of the month in which the Participation Fee is due, the Exchange will charge, and Contractor shall owe a 1% per month late fee on the unpaid balance as of that date. (e) In the event that Contractor disputes the amount of Participation Fees billed or deducted by the Exchange, Contractor shall submit a written notice of such dispute to the Exchange within thirty (30) days following receipt of such bill or deduction by the Exchange. Contractor’s notice will document the nature of the discrepancies, including, reconciliation of any differences identified by Contractor in enrollment or premiums collected. The Exchange will respond to Contractor within forty-five (45) days of receipt of the notice by either (i) paying the amount claimed by Contractor or (ii) providing a detailed explanation for the denial of the refund. If the Contractor still disputes the findings of the Exchange, Contractor may pursue additional remedies in accordance with Section 12.1. (f) Subject to the provisions of Section 10.5, Contractor agrees to a periodic audit or other examination by the Exchange or its designee regarding the computation and payment of Participation Fees. In the case of material non-compliance with Participation Fee payments, Contractor shall implement any necessary corrective action. The Exchange may perform follow up audits or examinations more frequently than annually to monitor Contractor’s implementation of such corrective actions. (g) Contractor acknowledges that the Exchange is required under Government Code §100520(c) to maintain a prudent reserve as determined by the Exchange.
Appears in 1 contract
Individual Exchange Participation Fees. (a) Contractor understands and agrees that (i) under the Affordable Care Act and the California Affordable Care Act, the Exchange may generate funds through a participation fee (“Participation Fees”) on Contractor’s QDPs and (ii) Contractor is responsible for the timely payment of any Participation Fees to the Exchange.
(b) Contractor recognizes that the total cost of all Participation Fees for the Exchange must be collected by Contractor by spreading the cost spread across the premiums charged to Contractor’s entire individual book of business in the single risk pool (both inside and outside the Exchange) for the Individual Exchange Participation Fees Market, and across Contractor’s entire book of business in the small employer single risk pool (both inside and outside the Exchange) for Covered California for Small Business Participation Fees. No rate charged to an Enrollee can have a higher per member per month fee to cover this overall Participation Fee than is charged to all other Enrollees of the respective risk poolsmall employer market.
(c) The Participation Fee payable to the Exchange during each month of this Agreement shall be equal to a per member per month four (“PMPM”4) rate percent of $.83 multiplied by the number of Enrollees gross premium attributable to each Enrollee in Contractor’s QDPs for such month. The Participation Fee will be assessed by the Exchange and payable monthly by Contractor based on enrollment the Exchange’s gross premium records attributable to Enrollees in Contractor's QDPs sold through the Individual Exchange for 2017-2019. The Participation Fee will be reviewed each year as part of the Exchange’s annual budget process. Should the Exchange need to collect or refund any premiums for years 2014 to 2016, the Participation Fee shall be calculated pursuant to the QDP Issuer Agreement that was in place during the applicable plan year or years.
(d) The Exchange will send invoices through email to Contractor monthly for Participation Fee invoices will be issued by Fees due to the Exchange prospectively to Contractor on the 15th of the month for the coming preceding month. The Exchange will provide the Contractor a Member Level Detail file to support the invoice. Contractor’s Participation Fee obligation invoice will be determined and billed by evaluating based on the Contractor’s then-current QDP confirmed enrollment enrollments in the preceding month based on the Exchange’s records and may be subject to adjustment adjusted to reflect changes in enrollment that may have occurred in prior months (including additions, terminations and cancellations of enrollmentenrollment or changes in gross premiums). However, Contractor may reconcile the invoice and remit payment only for those members who are enrolled in a QDP with Contractor in accordance with Billing Discrepancy Report in Attachment 13. Participation Fee payments will be due on 15 days from the 1st of date the month the Participation Fee coversinvoice is emailed to Contractor. For Participation Fees received invoices paid after 15 days from the 15th of date the month in which the Participation Fee invoice is dueemailed, the Exchange Contractor will charge, and Contractor shall owe be subject to a 1% per month late fee on the unpaid balance as of that date. The Exchange, in its sole discretion, may waive the late fee for any month if good cause exists for Contractor’s failure to make the payment by the due date.
(e) XxxXXXXX will serve as the system of record for Participation Fee xxxxxxxx. In the event that a Contractor disputes finds a discrepancy in the amount of Participation Fees billed or deducted by the Exchange, Contractor shall submit a written notice of such dispute to will resolve the Exchange within thirty (30) days following receipt of such bill underlying enrollment issues through the daily 834 interface, or deduction by the Exchange. Contractor’s notice will document the nature of the discrepancies, including, monthly member reconciliation of any differences identified by Contractor described in enrollment or premiums collected. The Exchange will respond to Contractor within forty-five (45) days of receipt of the notice by either (i) paying the amount claimed by Contractor or (ii) providing a detailed explanation for the denial of the refund. If the Contractor still disputes the findings of the Exchange, Contractor may pursue additional remedies in accordance with Section 12.12.1.
(f) Subject to the provisions of Section 10.5, Contractor agrees to a periodic audit or other examination by the Exchange or its designee regarding the computation and payment of Participation Fees. In the case of material non-compliance with Participation Fee payments, Contractor shall implement any necessary corrective action. The Exchange may perform follow up audits or examinations more frequently than annually to monitor Contractor’s implementation of such corrective actions.
(g) Contractor acknowledges that the Exchange is required under Government Code §100520(c) to maintain a prudent reserve as determined by the Exchange.
Appears in 1 contract
Individual Exchange Participation Fees. (a) Contractor understands and agrees that that: (i) under the Affordable Care Act and the California Affordable Care Act, the Exchange may generate funds through a participation fee (“Participation Fees”) on Contractor’s QDPs QHPs and (ii) Contractor is responsible for the timely payment of any Participation Fees to the Exchange.
(b) Contractor recognizes that the total cost of all Participation Fees for the Exchange must be collected by Contractor by spreading the cost across the premiums charged to Contractor’s entire individual risk pool (both inside and outside the Exchange) for the Individual Exchange Participation Fees and across the small employer risk pool (both inside and outside the Exchange) for Covered California for Small Business Participation Fees. No rate charged to an Enrollee can have a higher per member per month fee to cover this overall Participation Fee than is charged to all other Enrollees enrollees of the respective risk pool.
(c) The Participation Fee payable to the Exchange during each month of this Agreement shall be equal equal[DE(2] to to a per member per month (“PMPM”) rate of $.83 13.95 multiplied by the number of Enrollees 3.5 percent of the premium paid by each enrollee in Contractor’s QDPs QHPs for such month. The Participation Fee will be assessed by the Exchange and payable monthly by Contractor based on enrollment premiums paid by enrollees in Contractor's QDPs QHPs sold through the Individual Exchange for 201620167 - 2019.
(d) Participation Fee invoices will be issued by the Exchange prospectively to Contractor on the 15th of the month for the coming month. Contractor’s Participation Fee obligation will be determined and billed by evaluating Contractor’s then-current QDP QHP confirmed enrollment and may be subject to adjustment to reflect changes in enrollment that may have occurred in prior months (including additions, terminations and cancellations of enrollment). However, Contractor may reconcile the invoice and remit payment only for those members who are enrolled in a QDP QHP with Contractor in accordance with Billing Discrepancy Report Reporting requirement in Attachment 13. Participation Fee payments will be due on the 1st of the month the Participation Fee covers. For Participation Fees received after the 15th of the month in which the Participation Fee is due, the Exchange will charge, and Contractor shall owe owe, a 1% per month late fee on the unpaid balance as of that date.
(e) In the event that Contractor disputes the amount of Participation Fees billed or deducted by the Exchange, Contractor shall submit a written notice of such dispute to the Exchange within thirty (30) days following receipt of such bill or deduction by the Exchange. Contractor’s notice will document the nature of the discrepancies, including, reconciliation of any differences identified by Contractor in enrollment or premiums collected. The Exchange will respond to Contractor within forty-five (45) days of receipt of the notice by either (i) paying the amount claimed by Contractor or (ii) providing a detailed explanation for the denial of the refund. If the Contractor still disputes the findings of the Exchange, Contractor may pursue additional remedies in accordance with Section 12.1.
(f) Subject to the provisions of Section 10.5, Contractor agrees to a periodic audit or other examination by the Exchange or its designee regarding the computation and payment of Participation Fees. In the case of material non-compliance with Participation Fee payments, Contractor shall implement any necessary corrective action. The Exchange may perform follow up audits or examinations more frequently than annually to monitor Contractor’s implementation of such corrective actions.
(g) Contractor acknowledges that the Exchange is required under Government Code §100520(c) to maintain a prudent reserve as determined by the Exchange.
Appears in 1 contract
Individual Exchange Participation Fees. (
a) Contractor understands and agrees that that: (i) under the Affordable Care Act and the California Affordable Care Act, the Exchange may generate funds through a participation fee (“Participation Fees”) on Contractor’s QDPs QHPs and (ii) Contractor is responsible for the timely payment of any Participation Fees to the Exchange.
(b) Contractor recognizes that the total cost of all Participation Fees for the Exchange must be collected by Contractor by spreading the cost across the premiums charged to Contractor’s entire individual risk pool (both inside and outside the Exchange) for the Individual Exchange Participation Fees and across the small employer risk pool (both inside and outside the Exchange) for Covered California for Small Business Participation Fees. No rate charged to an Enrollee can have a higher per member per month fee to cover this overall Participation Fee than is charged to all other Enrollees enrollees of the respective risk pool.
(c) The Participation Fee payable to the Exchange during each month of this Agreement shall be equal equal[DE(2] to to a per member per month (“PMPM”) rate of $.83 13.95 multiplied by the number of Enrollees 3.5 percent of the premium paid by each Enrollee in Contractor’s QDPs QHPs for such month. The Participation Fee will be assessed by the Exchange and payable monthly by Contractor based on enrollment premiums paid by Enrollees in Contractor's QDPs QHPs sold through the Individual Exchange for 201620167 - 2019. The Participation Fee will be reviewed each year as part of the Exchange’s annual budget process.
(d) Participation Fee invoices will be issued by the Exchange prospectively retroactively to Contractor on the 15th of the month for the coming previous month. Contractor’s Participation Fee obligation will be determined and billed by evaluating Contractor’s then-then- current QDP QHP confirmed enrollment and may be subject to adjustment to reflect changes in enrollment that may have occurred in prior months (including additions, terminations and cancellations of enrollment). However, Contractor may reconcile the invoice and remit payment only for those members who are enrolled in a QDP QHP with Contractor in accordance with Billing Discrepancy Report Reporting requirement in Attachment 13. Participation Fee payments will be due on the 1st 25th of the following month the Participation Fee covers. For Participation Fees received after the 15th 125th of the month in which the Participation Fee is due, the Exchange will charge, and Contractor shall owe owe, a 1% per month late fee on the unpaid balance as of that date.
(e) In the event that Contractor disputes the amount of Participation Fees billed or deducted by the Exchange, Contractor shall submit a written notice of such dispute to the Exchange within thirty (30) days following receipt of such bill or deduction by the Exchange. Contractor’s notice will document the nature of the discrepancies, including, reconciliation of any differences identified by Contractor in enrollment or premiums collected. The Exchange will respond to Contractor within forty-five (45) days of receipt of the notice by either (i) paying the amount claimed by Contractor or (ii) providing a detailed explanation for the denial of the refund. If the Contractor still disputes the findings of the Exchange, Contractor may pursue additional remedies in accordance with Section 12.1.
(f) Subject to the provisions of Section 10.5, Contractor agrees to a periodic audit or other examination by the Exchange or its designee regarding the computation and payment of Participation Fees. In the case of material non-compliance with Participation Fee payments, Contractor shall implement any necessary corrective action. The Exchange may perform follow up audits or examinations more frequently than annually to monitor Contractor’s implementation of such corrective actions.
(g) Contractor acknowledges that the Exchange is required under Government Code §100520(c) to maintain a prudent reserve as determined by the Exchange.
Appears in 1 contract
Individual Exchange Participation Fees. (a) Contractor understands and agrees that that: (i) under the Affordable Care Act and the California Affordable Care Act, the Exchange may generate funds through a participation fee (“Participation Fees”) on Contractor’s QDPs QHPs and (ii) Contractor is responsible for the timely payment of any Participation Fees to the Exchange.
(b) Contractor recognizes that the total cost of all Participation Fees for the Exchange must be collected by Contractor by spreading the cost spread across the premiums charged to Contractor’s entire individual book of business in the single risk pool (both inside and outside the Exchange) for the Individual Exchange Participation Fees and across the small employer risk pool (both inside and outside the Exchange) for Covered California for Small Business Participation Fees. No rate charged to an Enrollee can have a higher per member per month fee to cover this overall Participation Fee than is charged to all other Enrollees of the respective risk poolMarket.
(c) The Participation Fee payable to the Exchange during each month of this Agreement shall be equal to a per member per month four (“PMPM”4) rate percent of $.83 multiplied by the number of Enrollees gross premium attributable to each Enrollee in Contractor’s QDPs QHPs for such month. The Participation Fee will be assessed by the Exchange and payable monthly by Contractor based on enrollment premiums paid by Enrollees in Contractor's QDPs QHPs sold through the Individual Exchange for 2017 - 2019. The Participation Fee will be reviewed each year as part of the Exchange’s annual budget process. Should the Exchange need to collect or refund any premiums for year 2014-2016, the Participation Fee shall be calculated pursuant to the QHP Issuer Agreement that was in place during the applicable plan year or years.
(d) Participation Fee invoices will be issued by the Exchange prospectively retroactively to Contractor on the 15th of the month for the coming previous month. Contractor’s Participation Fee obligation will be determined and billed by evaluating Contractor’s then-current QDP QHP confirmed enrollment and may be subject to adjustment to reflect changes in enrollment that may have occurred in prior months (including additions, terminations and cancellations of enrollment). However, Contractor may reconcile the invoice and remit payment only for those members who are enrolled in a QDP with Contractor in accordance with Billing Discrepancy Report in Attachment 13. Participation Fee payments will be due on the 1st 25th of the following month the Participation Fee covers. For Participation Fees received after the 15th 25th of the month in which the Participation Fee is due, the Exchange will charge, and Contractor shall owe owe, a 1% per month late fee on the unpaid balance as of that date.
(e) In the event that Contractor disputes the amount of Participation Fees billed or deducted by the Exchange, Contractor shall submit a written notice of such dispute to the Exchange within thirty (30) days following receipt of such bill or deduction by the Exchange. Contractor’s notice will document the nature of the discrepancies, including, reconciliation of any differences identified by Contractor in enrollment or premiums collected. The Exchange will respond to Contractor within forty-five (45) days of receipt of the notice by either (i) paying the amount claimed by Contractor or (ii) providing a detailed explanation for the denial of the refund. If the Contractor still disputes the findings of the Exchange, Contractor may pursue additional remedies in accordance with Section 12.1.
(f) Subject to the provisions of Section 10.5, Contractor agrees to a periodic audit or other examination by the Exchange or its designee regarding the computation and payment of Participation Fees. In the case of material non-compliance with Participation Fee payments, Contractor shall implement any necessary corrective action. The Exchange may perform follow up audits or examinations more frequently than annually to monitor Contractor’s implementation of such corrective actions.
(g) Contractor acknowledges that the Exchange is required under Government Code §100520(c) to maintain a prudent reserve as determined by the Exchange.
Appears in 1 contract
Individual Exchange Participation Fees. (a) Contractor understands and agrees that (i) under the Affordable Care Act and the California Affordable Care Act, the Exchange may generate funds through a participation fee (“Participation Fees”) on Contractor’s QDPs and (ii) Contractor is responsible for the timely payment of any Participation Fees to the Exchange.
(b) Contractor recognizes that the total cost of all Participation Fees for the Exchange must be collected by Contractor by spreading the cost spread across the premiums charged to Contractor’s entire individual book of business in the single risk pool (both inside and outside the Exchange) for the Individual Exchange Participation Fees Market, and across Contractor’s entire book of business in the small employer single risk pool (both inside and outside the Exchange) for Covered California for Small Business Participation Fees. No rate charged to an Enrollee can have a higher per member per month fee to cover this overall Participation Fee than is charged to all other Enrollees of the respective risk poolsmall employer market.
(c) The Participation Fee payable to the Exchange during each month of this Agreement shall be equal to a per member per month three point five (“PMPM”3. 5) rate percent of $.83 multiplied by the number of Enrollees gross premium attributable to each Enrollee in Contractor’s QDPs for such month. The Participation Fee will be assessed by the Exchange and payable monthly by Contractor based on enrollment the Exchange’s gross premium records attributable to effectuated Enrollees in Contractor's QDPs sold through the Individual Exchange for 2016.
(d) 2017-2020. The Participation Fee will be reviewed each year as part of the Exchange’s annual budget process. Should the Exchange need to record any positive or negative adjustments to enrollment activity for years 2014 to 2020, the Participation Fee shall be calculated pursuant to the Contractor’s Agreement that was in place during the applicable Plan Year or years. Participation Fee invoices will be issued by the Exchange prospectively to Contractor on the 15th of the month for the coming month. Contractor’s Participation Fee obligation will be determined and billed by evaluating Contractor’s then-current QDP confirmed effectuated enrollment and may be subject to adjustment to reflect changes in enrollment that may have occurred in prior months (including additions, terminations and cancellations of enrollment). However, Contractor may reconcile the invoice and remit payment only for those members who are enrolled in a QDP with Contractor in accordance with Billing Discrepancy Report in Attachment 13. Participation Fee payments will be due on fifteen (15) days from the 1st of date the month the Participation Fee coversinvoice is emailed to Contractor. For Participation Fees received invoices paid after fifteen (15) days from the 15th of date the month in which the Participation Fee invoice is dueemailed, the Exchange will charge, and Contractor shall owe may be assessed a 1% per month late fee on the unpaid balance as of that date. The Exchange, in its sole discretion, may assess the late fee for any month that Contractor fails to make the payment by the due date. Participation Fee payments will be applied to the oldest outstanding invoice or overall balance, including prior month late fees, whichever is greater.
(ed) In the event that Contractor disputes the amount of Participation Fees billed or deducted by the Exchange, Contractor shall submit a written notice of such dispute to the Exchange within thirty (30) days following receipt of such bill or deduction by the Exchange. Contractor’s notice will document the nature of the discrepancies, including, reconciliation of any differences identified by Contractor in enrollment or premiums collected. The Exchange will respond to Contractor within forty-five (45) days of receipt of the notice by either (i) paying the amount claimed by Contractor or (ii) providing a detailed explanation for the denial of the refund. If the Contractor still disputes the findings of the Exchange, Contractor may pursue additional remedies in accordance with Section 12.1.
(f) Subject to the provisions of Section 10.5, Contractor agrees to a periodic audit or other examination by the Exchange or its designee regarding the computation and payment of Participation Fees. In the case of material non-compliance with Participation Fee payments, Contractor shall implement any necessary corrective action. The Exchange may perform follow up audits or examinations more frequently than annually to monitor Contractor’s implementation of such corrective actions.
(g) Contractor acknowledges that the Exchange is required under Government Code §100520(c) to maintain a prudent reserve as determined by the Exchange.thirty
Appears in 1 contract
Individual Exchange Participation Fees. (a) Contractor understands and agrees that (i) under the Affordable Care Act and the California Affordable Care Act, the Exchange may generate funds through a participation fee (“Participation Fees”) on Contractor’s QDPs and (ii) Contractor is responsible for the timely payment of any Participation Fees to the Exchange.
(b) Contractor recognizes that the total cost of all Participation Fees for the Exchange must be collected by Contractor by spreading the cost spread across the premiums charged to Contractor’s entire individual book of business in the single risk pool (both inside and outside the Exchange) for the Individual Exchange Participation Fees Market, and across Contractor’s entire book of business in the small employer single risk pool (both inside and outside the Exchange) for Covered California for Small Business Participation Fees. No rate charged to an Enrollee can have a higher per member per month fee to cover this overall Participation Fee than is charged to all other Enrollees of the respective risk poolsmall employer market.
(c) The Participation Fee payable to the Exchange during each month of this Agreement shall be equal to a per member per month four (“PMPM”4) rate percent of $.83 multiplied by the number of Enrollees gross premium attributable to each Enrollee in Contractor’s QDPs for such month. The Participation Fee will be assessed by the Exchange and payable monthly by Contractor based on enrollment gross premium attributable to Enrollees in Contractor's QDPs sold through the Individual Exchange for 2017-2019. The Participation Fee will be reviewed each year as part of the Exchange’s annual budget process. Should the Exchange need to collect or refund any premiums for years 2014 to 2016, the Participation Fee shall be calculated pursuant to the QDP Issuer Agreement that was in place during the applicable plan year or years.
(d) Participation Fee invoices will be issued by the Exchange prospectively retroactively to Contractor on the 15th of the month for the coming previous month. Contractor’s Participation Fee obligation will be determined and billed by evaluating Contractor’s then-current QDP confirmed enrollment and may be subject to adjustment to reflect changes in enrollment that may have occurred in prior months (including additions, terminations and cancellations of enrollment). However, Contractor may reconcile the invoice and remit payment only for those members who are enrolled in a QDP with Contractor in accordance with Billing Discrepancy Report in Attachment 13. Participation Fee payments will be due on the 1st 25th of the following month the Participation Fee covers. For Participation Fees received after the 15th 25th of the month in which the Participation Fee is due, the Exchange will charge, and Contractor shall owe a 1% per month late fee on the unpaid balance as of that date.
(e) In the event that Contractor disputes the amount of Participation Fees billed or deducted by the Exchange, Contractor shall submit a written notice of such dispute to the Exchange within thirty (30) days following receipt of such bill or deduction by the Exchange. Contractor’s notice will document the nature of the discrepancies, including, reconciliation of any differences identified by Contractor in enrollment or premiums collected. The Exchange will respond to Contractor within forty-five (45) days of receipt of the notice by either (i) paying the amount claimed by Contractor or (ii) providing a detailed explanation for the denial of the refund. If the Contractor still disputes the findings of the Exchange, Contractor may pursue additional remedies in accordance with Section 12.1.
(f) Subject to the provisions of Section 10.5, Contractor agrees to a periodic audit or other examination by the Exchange or its designee regarding the computation and payment of Participation Fees. In the case of material non-compliance with Participation Fee payments, Contractor shall implement any necessary corrective action. The Exchange may perform follow up audits or examinations more frequently than annually to monitor Contractor’s implementation of such corrective actions.
(g) Contractor acknowledges that the Exchange is required under Government Code §100520(c) to maintain a prudent reserve as determined by the Exchange.thirty
Appears in 1 contract
Individual Exchange Participation Fees. (a) Contractor understands and agrees that that: (i) under the Affordable Care Act and the California Affordable Care Act, the Exchange may generate funds through a participation fee (“Participation Fees”) on Contractor’s QDPs QHPs and (ii) Contractor is responsible for the timely payment of any Participation Fees to the Exchange.
(b) Contractor recognizes that the total cost of all Participation Fees for the Exchange must be collected by Contractor by spreading the cost spread across the premiums charged to Contractor’s entire individual book of business in the single risk pool (both inside and outside the Exchange) for the Individual Exchange Participation Fees and across the small employer risk pool (both inside and outside the Exchange) for Covered California for Small Business Participation Fees. No rate charged to an Enrollee can have a higher per member per month fee to cover this overall Participation Fee than is charged to all other Enrollees of the respective risk poolMarket.
(c) The Participation Fee payable to the Exchange during each month of this Agreement shall be equal to a per member per month four (“PMPM”4) rate percent of $.83 multiplied by the number of Enrollees gross premium attributable to each Enrollee in Contractor’s QDPs QHPs for such month. The Participation Fee will be assessed by the Exchange and payable monthly by Contractor based on enrollment the Exchange’s gross premium records attributable to Enrollees in Contractor's QDPs QHPs sold through the Individual Exchange for 2017 - 2019. The Participation Fee will be reviewed each year as part of the Exchange’s annual budget process. Should the Exchange need to collect or refund any premiums for year 2014-2016, the Participation Fee shall be calculated pursuant to the QHP Issuer Agreement that was in place during the applicable plan year or years.
(d) The Exchange will send invoices through email to Contractor monthly for Participation Fee invoices will be issued by Fees due to the Exchange prospectively to Contractor on the 15th of the month for the coming preceding month. The Exchange will provide the Contractor a Member Level Detail file to support that invoice. Contractor’s Participation Fee obligation invoice will be determined and billed by evaluating based on Contractor’s then-current QDP confirmed enrollment QHP enrollments in the preceding month based on the Exchange’s records and may be subject to adjustment adjusted to reflect changes in enrollment that may have occurred in prior months (including additions, terminations and cancellations of enrollmentenrollment or changes in gross premiums). However, Contractor may reconcile the invoice and remit payment only for those members who are enrolled in a QDP with Contractor in accordance with Billing Discrepancy Report in Attachment 13. Participation Fee payments will be due on 15 days from the 1st of date the month the Participation Fee coversinvoice is emailed to Contractor. For Participation Fees received invoices paid after 15 days from the 15th of date the month in which the Participation Fee invoice is dueemailed, the Exchange Contractor will charge, and Contractor shall owe be subject to a 1% per month late fee on the unpaid balance as of that date. The Exchange, in its sole discretion, may waive the late fee for any month if good cause exists for Contractor’s failure to make the payment by the due date.
(e) XxxXXXXX will serve as the system of record for Participation Fee xxxxxxxx. In the event that a Contractor disputes finds a discrepancy in the amount of Participation Fees billed or deducted by the Exchange, Contractor shall submit a written notice of such dispute to will resolve the Exchange within thirty (30) days following receipt of such bill underlying enrollment issues through the daily 834 interface, or deduction by the Exchange. Contractor’s notice will document the nature of the discrepancies, including, monthly member reconciliation of any differences identified by Contractor described in enrollment or premiums collected. The Exchange will respond to Contractor within forty-five (45) days of receipt of the notice by either (i) paying the amount claimed by Contractor or (ii) providing a detailed explanation for the denial of the refund. If the Contractor still disputes the findings of the Exchange, Contractor may pursue additional remedies in accordance with Section 12.12.1.
(f) Subject to the provisions of Section 10.5, Contractor agrees to a periodic audit or other examination by the Exchange or its designee regarding the computation and payment of Participation Fees. In the case of material non-compliance with Participation Fee payments, Contractor shall implement any necessary corrective action. The Exchange may perform follow up audits or examinations more frequently than annually to monitor Contractor’s implementation of such corrective actions.
(g) Contractor acknowledges that the Exchange is required under Government Code §100520(c) to maintain a prudent reserve as determined by the Exchange.
Appears in 1 contract
Individual Exchange Participation Fees. (a) Contractor understands and agrees that that: (i) under the Affordable Care Act and the California Affordable Care Act, the Exchange may generate funds through a participation fee (“Participation Fees”) on Contractor’s QDPs QHPs, and (ii) Contractor is responsible for the timely payment of any Participation Fees to the Exchange.
(b) Contractor recognizes that the total cost of all Participation Fees for the Exchange must be collected by Contractor by spreading the cost spread across the premiums charged to Contractor’s entire individual book of business in the single risk pool (both inside and outside the Exchange) for the Individual Exchange Participation Fees and across the small employer risk pool (both inside and outside the Exchange) for Covered California for Small Business Participation Fees. No rate charged to an Enrollee can have a higher per member per month fee to cover this overall Participation Fee than is charged to all other Enrollees of the respective risk poolMarket.
(c) The Participation Fee payable to the Exchange during each month of this Agreement the 2019 Plan Year shall be equal to a per member per month three point seven-five (“PMPM”3.75) rate percent of $.83 multiplied by the number of Enrollees gross premium attributable to each Enrollee in Contractor’s QDPs QHPs for such month. The Participation Fee will be assessed by the Exchange and payable monthly by Contractor based on enrollment the Exchange’s gross premium records attributable to Enrollees in Contractor's QDPs QHPs sold through the Individual Exchange for 20162017-2019. In the case of partial month enrollments, Participation Fees will be adjusted based on the methodology specified in 10 CCR § 6500 (i). The Participation Fee will be reviewed each year as part of the Exchange’s annual budget process. Should the Exchange need to collect or refund any premiums for year 2014-2018, the Participation Fee shall be calculated pursuant to the QHP Issuer Agreement that was in place during the applicable Plan Year or years.
(d) The Exchange will send invoices through email to Contractor monthly for Participation Fee invoices will be issued by Fees due to the Exchange prospectively to Contractor on the 15th of the month for the coming preceding month. The Exchange will provide the Contractor a Member Level Detail file to support that invoice. Contractor’s Participation Fee obligation invoice will be determined and billed by evaluating based on Contractor’s then-current QDP confirmed enrollment QHP enrollments in the preceding month based on the Exchange’s records and may be subject to adjustment adjusted to reflect changes in enrollment that may have occurred in prior months (including additions, terminations terminations, and cancellations of enrollmentenrollment or changes in gross premiums). However, Contractor may reconcile the invoice and remit payment only for those members who are enrolled in a QDP with Contractor in accordance with Billing Discrepancy Report in Attachment 13. Participation Fee payments will be due on 15 days from the 1st of date the month the Participation Fee coversinvoice is emailed to Contractor. For Participation Fees received invoices paid after 15 days from the 15th of date the month in which the Participation Fee invoice is dueemailed, the Exchange Contractor will charge, and Contractor shall owe be subject to a 1% per month late fee on the unpaid balance as of that date. The Exchange may only charge one late fee per invoice. The Exchange, in its sole discretion, may waive the late fee for any month if good cause exists for Contractor’s failure to make the payment by the due date. Participation Fee payments will be applied to the oldest outstanding invoice or overall balance, including prior month late fees, whichever is greater.
(e) XxxXXXXX will serve as the system of record for Participation Fee xxxxxxxx. In the event that a Contractor disputes finds a discrepancy in the amount of Participation Fees billed or deducted by the Exchange, Contractor shall submit a written notice of such dispute to will resolve the Exchange within thirty (30) days following receipt of such bill underlying enrollment issues through the daily 834 interface, or deduction by the Exchange. Contractor’s notice will document the nature of the discrepancies, including, monthly member reconciliation of any differences identified by Contractor described in enrollment or premiums collected. The Exchange will respond to Contractor within forty-five (45) days of receipt of the notice by either (i) paying the amount claimed by Contractor or (ii) providing a detailed explanation for the denial of the refund. If the Contractor still disputes the findings of the Exchange, Contractor may pursue additional remedies in accordance with Section 12.12.1.
(f) Subject to the provisions of Section 10.5, Contractor agrees to a periodic audit or other examination by the Exchange or its designee regarding the computation and payment of Participation Fees. In the case of material non-compliance with Participation Fee payments, Contractor shall implement any necessary corrective action. The Exchange may perform follow up audits or examinations more frequently than annually to monitor Contractor’s implementation of such corrective actions.
(g) Contractor acknowledges that the Exchange is required under Government Code §100520(c) to maintain a prudent reserve as determined by the Exchange.
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Individual Exchange Participation Fees. (a) Contractor understands and agrees that that: (i) under the Affordable Care Act and the California Affordable Care Act, the Exchange may generate funds through a participation fee (“Participation Fees”) on Contractor’s QDPs QHPs and (ii) Contractor is responsible for the timely payment of any Participation Fees to the Exchange.
(b) Contractor recognizes that the total cost of all Participation Fees for the Exchange must be collected by Contractor by spreading the cost across the premiums charged to Contractor’s entire individual risk pool (both inside and outside the Exchange) for the Individual Exchange Participation Fees and across the small employer risk pool (both inside and outside the Exchange) for Covered California for Small Business Participation Fees. No rate charged to an Enrollee can have a higher per member per month fee to cover this overall Participation Fee than is charged to all other Enrollees enrollees of the respective risk pool.
(c) The Participation Fee payable to the Exchange during each month of this Agreement shall be equal to a per member per month (“PMPM”) rate 3.5 percent of $.83 multiplied the premium paid by the number of Enrollees each enrollee in Contractor’s QDPs QHPs for such month. The Participation Fee will be assessed by the Exchange and payable monthly by Contractor based on enrollment premiums paid by enrollees in Contractor's QDPs QHPs sold through the Individual Exchange for 20162017 - 2019.
(d) Participation Fee invoices will be issued by the Exchange prospectively to Contractor on the 15th of the month for the coming month. Contractor’s Participation Fee obligation will be determined and billed by evaluating Contractor’s then-current QDP QHP confirmed enrollment and may be subject to adjustment to reflect changes in enrollment that may have occurred in prior months (including additions, terminations and cancellations of enrollment). However, Contractor may reconcile the invoice and remit payment only for those members who are enrolled in a QDP QHP with Contractor in accordance with Billing Discrepancy Report Reporting requirement in Attachment 13. Participation Fee payments will be due on the 1st of the month the Participation Fee covers. For Participation Fees received after the 15th of the month in which the Participation Fee is due, the Exchange will charge, and Contractor shall owe owe, a 1% per month late fee on the unpaid balance as of that date.
(e) In the event that Contractor disputes the amount of Participation Fees billed or deducted by the Exchange, Contractor shall submit a written notice of such dispute to the Exchange within thirty (30) days following receipt of such bill or deduction by the Exchange. Contractor’s notice will document the nature of the discrepancies, including, reconciliation of any differences identified by Contractor in enrollment or premiums collected. The Exchange will respond to Contractor within forty-five (45) days of receipt of the notice by either (i) paying the amount claimed by Contractor or (ii) providing a detailed explanation for the denial of the refund. If the Contractor still disputes the findings of the Exchange, Contractor may pursue additional remedies in accordance with Section 12.1.
(f) Subject to the provisions of Section 10.5, Contractor agrees to a periodic audit or other examination by the Exchange or its designee regarding the computation and payment of Participation Fees. In the case of material non-compliance with Participation Fee payments, Contractor shall implement any necessary corrective action. The Exchange may perform follow up audits or examinations more frequently than annually to monitor Contractor’s implementation of such corrective actions.
(g) Contractor acknowledges that the Exchange is required under Government Code §100520(c) to maintain a prudent reserve as determined by the Exchange.
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Individual Exchange Participation Fees. (a) Contractor understands and agrees that (i) under the Affordable Care Act and the California Affordable Care Act, the Exchange may generate funds through a participation fee (“Participation ³Participation Fees”´) on Contractor’s Contractor¶s QDPs and (ii) Contractor is responsible for the timely payment of any Participation Fees to the Exchange.
(b) Contractor recognizes that the total cost of all Participation Fees for the Exchange must be collected by Contractor by spreading the cost across the premiums charged to Contractor’s Contractor¶s entire individual risk pool (both inside and outside the Exchange) for the Individual Exchange Participation Fees and across the small employer risk pool (both inside and outside the Exchange) for Covered California for Small Business Participation Fees. No rate charged to an Enrollee can have a higher per member per month fee to cover this overall Participation Fee than is charged to all other Enrollees of the respective risk pool.. Enrollees3.5
(c) The Participation Fee payable to the Exchange during each month of this Agreement shall be equal to a per member per month (“PMPM”³PMPM´) rate of $.83 multiplied by the number of Enrollees percent of the premium paid by each eEnrollee [FS(1] in Contractor’s Contractor¶s QDPs for such month. The Participation Fee will be assessed by the Exchange and payable monthly by Contractor based on enrollment enrollmentpremiums paid by enrollees in Contractor's QDPs sold through the Individual Exchange for 201620167-2019. The Participation Fee will be reviewed each year as part of the Exchange¶s annual budget process.
(d) Participation Fee invoices will be issued by the Exchange prospectively retroactively to Contractor on the 15th th of the month for the coming previous month. Contractor’s Participation Contractor¶sParticipation Fee obligation will be determined and billed by evaluating Contractor’s Contractor¶s then-current QDP confirmed enrollment and may be subject to adjustment to reflect changes in enrollment that may have occurred in prior months (including additions, terminations and cancellations of enrollment). However, Contractor may reconcile the invoice and remit payment only for those members who are enrolled in a QDP with Contractor in accordance with Billing Discrepancy Report in Attachment 13. Participation Fee payments will be due on the 1st 25th of the following month the Participation Fee covers. For Participation Fees received after the 15th 25th of the month in which the Participation Fee is due, the Exchange will charge, and Contractor shall owe a 1% per month late fee on the unpaid balance as of that date.
(e) In the event that Contractor disputes the amount of Participation Fees billed or deducted by the Exchange, Contractor shall submit a written notice of such dispute to the Exchange within thirty (30) days following receipt of such bill or deduction by the Exchange. Contractor’s notice will document the nature of the discrepancies, including, reconciliation of any differences identified by Contractor in enrollment or premiums collected. The Exchange will respond to Contractor within forty-five (45) days of receipt of the notice by either (i) paying the amount claimed by Contractor or (ii) providing a detailed explanation for the denial of the refund. If the Contractor still disputes the findings of the Exchange, Contractor may pursue additional remedies in accordance with Section 12.1.
(f) Subject to the provisions of Section 10.5, Contractor agrees to a periodic audit or other examination by the Exchange or its designee regarding the computation and payment of Participation Fees. In the case of material non-compliance with Participation Fee payments, Contractor shall implement any necessary corrective action. The Exchange may perform follow up audits or examinations more frequently than annually to monitor Contractor’s implementation of such corrective actions.
(g) Contractor acknowledges that the Exchange is required under Government Code §100520(c) to maintain a prudent reserve as determined by the Exchange.thirty
Appears in 1 contract
Individual Exchange Participation Fees. (a) Contractor understands and agrees that (i) under the Affordable Care Act and the California Affordable Care Act, the Exchange may generate funds through a participation fee (“Participation Fees”) on Contractor’s QDPs and (ii) Contractor is responsible for the timely payment of any Participation Fees to the Exchange.
(b) Contractor recognizes that the total cost of all Participation Fees for the Exchange must be collected by Contractor by spreading the cost spread across the premiums charged to Contractor’s entire individual book of business in the single risk pool (both inside and outside the Exchange) for the Individual Exchange Participation Fees Market, and across Contractor’s entire book of business in the small employer single risk pool (both inside and outside the Exchange) for Covered California for Small Business Participation Fees. No rate charged to an Enrollee can have a higher per member per month fee to cover this overall Participation Fee than is charged to all other Enrollees of the respective risk poolsmall employer market.
(c) The Participation Fee payable to the Exchange during each month of this Agreement shall be equal to a per member per month three point seven-five (“PMPM”3.75) rate percent of $.83 multiplied by the number of Enrollees gross premium attributable to each Enrollee in Contractor’s QDPs for such month. The Participation Fee will be assessed by the Exchange and payable monthly by Contractor based on enrollment the Exchange’s gross premium records attributable to Enrollees in Contractor's QDPs sold through the Individual Exchange for 2016.
(d) 2017-2019. The Participation Fee invoices will be issued by reviewed each year as part of the Exchange’s annual budget process. Should the Exchange prospectively need to collect or refund any premiums for years 2014 to 2018, the Participation Fee shall be calculated pursuant to the QDP Issuer Agreement that was in place during the applicable plan year or years. In the case of partial month enrollments, Participation Fees will be adjusted based on the methodology specified in 10 CCR § 6500(i). The Exchange will send invoices through email to Contractor on monthly for Participation Fees due to the 15th of the month Exchange for the coming preceding month. The Exchange will provide the Contractor a Member Level Detail file to support the invoice. Contractor’s Participation Fee obligation invoice will be determined and billed by evaluating based on the Contractor’s then-current QDP confirmed enrollment enrollments in the preceding month based on the Exchange’s records and may be subject to adjustment adjusted to reflect changes in enrollment that may have occurred in prior months (including additions, terminations and cancellations of enrollmentenrollment or changes in gross premiums). However, Contractor may reconcile the invoice and remit payment only for those members who are enrolled in a QDP with Contractor in accordance with Billing Discrepancy Report in Attachment 13. Participation Fee payments will be due on fifteen (15) days from the 1st of date the month the Participation Fee coversinvoice is emailed to Contractor. For Participation Fees received invoices paid after fifteen (15) days from the 15th of date the month in which the Participation Fee invoice is dueemailed, the Exchange Contractor will charge, and Contractor shall owe be subject to a 1% per month late fee on the unpaid balance as of that date. The Exchange may only charge one late fee per invoice. The Exchange, in its sole discretion, may waive the late fee for any month if good cause exists for Contractor’s failure to make the payment by the due date. Participation Fee payments will be applied to the oldest outstanding invoice or overall balance, including prior month late fees, whichever is greater.
(ed) XxxXXXXX will serve as the system of record for Participation Fee xxxxxxxx. In the event that a Contractor disputes finds a discrepancy in the amount of Participation Fees billed or deducted by the Exchange, Contractor shall submit a written notice of such dispute to will resolve the Exchange within thirty (30) days following receipt of such bill underlying enrollment issues through the daily 834 interface, or deduction by the Exchange. Contractor’s notice will document the nature of the discrepancies, including, monthly member reconciliation of any differences identified by Contractor described in enrollment or premiums collected. The Exchange will respond to Contractor within forty-five (45) days of receipt of the notice by either (i) paying the amount claimed by Contractor or (ii) providing a detailed explanation for the denial of the refund. If the Contractor still disputes the findings of the Exchange, Contractor may pursue additional remedies in accordance with Section 12.12.1.
(f) Subject to the provisions of Section 10.5, Contractor agrees to a periodic audit or other examination by the Exchange or its designee regarding the computation and payment of Participation Fees. In the case of material non-compliance with Participation Fee payments, Contractor shall implement any necessary corrective action. The Exchange may perform follow up audits or examinations more frequently than annually to monitor Contractor’s implementation of such corrective actions.
(g) Contractor acknowledges that the Exchange is required under Government Code §100520(c) to maintain a prudent reserve as determined by the Exchange.
Appears in 1 contract
Individual Exchange Participation Fees. (a) Contractor understands and agrees that that: (i) under the Affordable Care Act and the California Affordable Care Act, the Exchange may generate funds through a participation fee (“Participation Fees”) on Contractor’s QDPs QHPs, and (ii) Contractor is responsible for the timely payment of any Participation Fees to the Exchange.
(b) Contractor recognizes that the total cost of all Participation Fees for the Exchange must be collected by Contractor by spreading the cost spread across the premiums charged to Contractor’s entire individual book of business in the single risk pool (both inside and outside the Exchange) for the Individual Exchange Participation Fees and across the small employer risk pool (both inside and outside the Exchange) for Covered California for Small Business Participation Fees. No rate charged to an Enrollee can have a higher per member per month fee to cover this overall Participation Fee than is charged to all other Enrollees of the respective risk poolMarket.
(c) The Participation Fee payable to the Exchange during each month of this Agreement shall be equal to a per member per month three point five (“PMPM”3.5) rate percent of $.83 multiplied by the number of Enrollees gross premium attributable to each Enrollee in Contractor’s QDPs QHPs for such month. The Participation Fee will be assessed by the Exchange and payable monthly by Contractor based on enrollment the Exchange’s gross premium records attributable to effectuated Enrollees in Contractor's QDPs QHPs sold through the Individual Exchange for 20162017-2020. The Participation Fee will be reviewed each year as part of the Exchange’s annual budget process. Should the Exchange need to record any positive or negative adjustments to enrollment activity for year 2014-2020, the Participation Fee shall be calculated pursuant to the Contractor’s Agreement that was in place during the applicable Plan Year or years.
(d) Participation Fee invoices will be issued by the Exchange prospectively to Contractor on the 15th of the month for the coming month. Contractor’s Participation Fee obligation will be determined and billed by evaluating Contractor’s then-current QDP confirmed QHP effectuated enrollment and may be subject to adjustment to reflect changes in enrollment that may have occurred in prior months (including additions, terminations and cancellations of enrollment). However, Contractor may reconcile the invoice and remit payment only for those members who are enrolled in a QDP with Contractor in accordance with Billing Discrepancy Report in Attachment 13. Participation Fee payments will be due on 15 days from the 1st of date the month the Participation Fee coversinvoice is emailed to Contractor. For Participation Fees received invoices paid after 15 days from the 15th of date the month in which the Participation Fee invoice is dueemailed, the Exchange will charge, and Contractor shall owe may be assessed a 1% per month late fee on the unpaid balance as of that date. The Exchange, in its sole discretion, may assess the late fee for any month that Contractor fails to make the payment by the due date. Participation Fee payments will be applied to the oldest outstanding invoice or overall balance, including prior month late fees, whichever is greater.
(e) In the event that Contractor disputes the amount of Participation Fees billed or deducted by the Exchange, Contractor shall submit a written notice of such dispute to the Exchange within thirty (30) days following receipt of such bill or deduction by the Exchange. Contractor’s notice will document the nature of the discrepancies, including, reconciliation of any differences identified by Contractor in enrollment or premiums collected. The Exchange will respond to Contractor within forty-five (45) days of receipt of the notice by either (i) paying the amount claimed by Contractor or (ii) providing a detailed explanation for the denial of the refund. If the Contractor still disputes the findings of the Exchange, Contractor may pursue additional remedies in accordance with Section 12.1.
(f) Subject to the provisions of Section 10.5, Contractor agrees to a periodic audit or other examination by the Exchange or its designee regarding the computation and payment of Participation Fees. In the case of material non-compliance with Participation Fee payments, Contractor shall implement any necessary corrective action. The Exchange may perform follow up audits or examinations more frequently than annually to monitor Contractor’s implementation of such corrective actions.
(g) Contractor acknowledges that the Exchange is required under Government Code §§ 100520(c) to maintain a prudent reserve as determined by the Exchange.
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